Unintended Consequences of Emergency Contraception Availability

Transcription

1 Unintended Consequences of Emergency Contraception Availability Ana Nuevo-Chiquero Francisco J. Pino January 31, 2015 Preliminary and incomplete; please do not circulate Abstract This paper examines the impact of changes in emergency contraception availability in Chile over the period Using variation over time - due to country-level legislative changes - and at the municipality level - due to the major s political affiliation-, we study the effects of emergency contraception availability in risky sexual activity, births across population subgroups and incidence of sexually transmitted diseases. Preliminary results indicate that lack of access increased the use of regular contraceptive methods among young individuals. Availability of postintercourse contraception reduced the number of births only to women with low or no formal education, and does not appear to increase significantly the incidence of sexually transmitted diseases, suggesting that compensating behaviors do not overcome the benefits from emergency contraception availability. Extended Abstract Family planning programs have been an essential part of the development agenda for a few decades (UNFPA, 2012). However, the direction of the causality between contraceptive availability and development is still unclear. Does development reduce the demand for children hence increasing the demand for contraception or does contraception InstEAD, Department of Economics, University of Sheffield ECARES, Université Libre de Bruxelles 1

2 and the reduction in population growth play a key role in development? Even in developed countries, the historical consequences of the introduction of modern contraceptive methods are still subject to debate. 1 Contraceptive use reduces the risk of undesired consequences from sexual intercourse, freeing women and partners from the cost of unwanted fertility. This in turn affects education, labor force participation, income or child investments (Goldin and Katz, 2002). However, easier access to contraception will reduce the cost of engaging in sexual intercourse, and increases in sexual activity could (partially or totally) compensate the effect of the decrease in the probability of the undesired outcome. A similar mechanism operates in the case of abortion: abortion availability should decrease unwanted births unless the increase in unprotected sexual activity compensates for the reduction of pregnancies that are taken to term. Hence, the net effect has been regarded as an empirical question. Emergency Contraception (EC), also known as the morning after pill, lays between abortion and regular contraception. Unlike regular contraception, it can be taken once sexual activity has taken place, but the time window for its intake prevents any update in information (the occurrence of conception or an updated cost of giving birth) that is likely to occur in the case of abortion. 2 Since its introduction in 1980s, the conditions in which it can be accessed have substantially varied across countries and over time. The literature has reported only limited impact of EC in developed countries. For instance, Girma and Paton (2011) found no effect in teen births after an improvement on access in the UK, but an increase in sexually transmitted diseases. In the U.S., Gross, Lafortune and Low (2013) report no effect on birth or abortion, but a decrease in reports of sexual assault when they become unnecessary to access EC. In this paper we exploit changes in the distribution of Emergency Contraception in Chile in to analyze the effects of its availability in women s behaviour and outcomes. The context of Chile is ideal for analyzing the effects of EC for various reasons. First, teenage pregnancy is still a relevant issue, with 55 births per 1,000 women between ages 15 to 19 in 2012 (compared to 33 for U.S. or 11 for Spain). In addition, Chile has a relatively low rate of contraceptive use (58 percent), even compared to other Latin American countries such as Brazil (80 percent), Uruguay (78 percent), Mexico, or Peru 1 Goldin (1990) credits the pill for the increase in female labour force participation in the US after World War II, while other authors argue that most of the fertility transition happened before the introduction of the contraceptive pill. 2 EC reduces the probability of pregnancy from 42 to 95 percent, depending on the time passed between sexual activity and its intake, but it offers only a 5-day window for its intake. 2

3 (both 71 percent). Second, Chile is one of the few countries where abortion is illegal, even in cases of rape or to save the mother s life. 3 Finally, between years 2007 and 2010 there were a series of measures and counter-measures to allow/block the distribution of the EC pill. This produced changes in EC availability across municipalities and over time that we exploit to identify a causal effect. We analyze the impact of EC availability in a wide range of outcomes. First, we examine whether birth rates were affected by EC availability. As in the case of abortion, EC will reduce unwanted births if there is no compensating behavior (i.e., if the level of unprotected sexual relations is unaffected). We also focus on groups with a higher risk of unplanned pregnancies, namely women below age 20, single women and women with low education. We then analyze various birth outcomes (gestational length, birth weight and length) to assess whether there is a selection effect in children born when the EC is distributed, as it is found by Ananat, Gruber, Levine and Staiger (2009) for the introduction of abortion and by Ananat and Hungerman (2012) for the case of contraception. Furthermore, we examine the impact of EC on sexually-transmitted diseases (STDs), such as gonorrhoea and syphilis. STDs can be regarded as proxies for risky sexual behavior (e.g. Klick and Stratmann, 2007; Girma and Paton, 2011). Finally, we exploit variation coming from political affiliation of the major (as a proxy for the likelihood of EC distribution in municipal clinics) in contraceptive use of young individuals (15 to 24), with a focus on municipalities with close elections. This paper contributes to the scarce literature examining the impact of contraception availability in developing countries, and, in particular, the effect of EC. 4 Furthermore, most studies of the effect of EC availability rely on comparing areas where EC is available due to changes in regulation to areas where it is not (e.g. Girma and Paton, 2006 and 2011; Gross et al., 2013). This approach assumes that the policy is implemented in all areas equally (another interpretation is that it gives the effect for the average implementation ). Our approach differs in that we gathered data on the number of EC doses distributed by the Ministry of Health s drug supplier (CENABAST). By using this administrative 3 In Latin America, only El Salvador and Honduras have a similarly restrictive legislation, but it is commonly the case in Sub-Saharan Africa. While this may affect the external validity of our results, it simplifies the estimation procedure, since there is possible substitution between contraception and abortion. 4 Betancor and Clarke (2014) is a notable exception. They examine a subset of the changes occurred in Chile over a shorter period (3 years), and use a yearly survey of EC distribution in local clinics to estimate a municipality fixed-effect model. 3

4 data we have a measure of policy implementation. We combine the EC dataset with other sources of administrative data for birth statistics, sexually transmitted diseases, and municipality characteristics. Finally, we rely on National Youth Surveys (Encuestas Nacionales de Juventud) to test for behavioral changes in contraceptive use in a group of interest. Our results show that EC availability has no effect on the number of births for the population as a whole. However, it does reduce the number of births for women with low or no education. The effect is statistically significant but small in magnitude: An increase of 80 doses distributed (equivalent to 1 standard deviation) reduces the number of births in this group by 0.17, or 2 percent. We also find a small but statistically significant reduction in the average gestational length due to the introduction of the EC. Finally, we do not find evidence of a risk adjusting behavior, since EC availability does not increase the prevalence of STDs, although within the youth sample, individuals in municipalities less likely to EC are more likely to use any contraception that their counterparts. References Ananat, E. O., Gruber, J., Levine, P. B. and Staiger, D. (2009). Abortion and selection. Review of Economics and Statistics, 91 (1), and Hungerman, D. M. (2012). The power of the pill for the next generation: Oral contraception s effects on fertility, abortion, and maternal and child characteristics. Review of Economics and Statistics, 94 (1), Betancor, A. and Clarke, D. (2014). Assessing plan b: The effect of the morning after pill on children and women. Unpublished Manuscript. Girma, S. and Paton, D. (2006). Matching estimates of the impact of over-the-counter emergency birth control on teenage pregnancy. Health Economics, 15 (9), and (2011). The impact of emergency birth control on teen pregnancy and stis. Journal of Health Economics, 30 (2), Goldin, C. (1990). Understanding the Gender Gap. New York: Oxford University Press. and Katz, L. F. (2002). The power of the pill: Oral contraceptives and women s career and marriage decisions. Journal of Political Economy, 110 (4). Gross, T., Lafortune, J. and Low, C. (2013). What happens the morning after? the costs and benefits of expanding access to emergency contraception. Journal of Policy Analysis and Management, 33 (1),

5 Klick, J. and Stratmann, T. (2007). Abortion access and risky sex among teens: Parental involvement laws and sexually transmitted diseases. Journal of Law, Economics & Organization, 24 (1), UNFPA (2012). Choices not Chance UNFPA Family Planning Strategy Tech. rep., United Nations Population Fund. 5